Preparing for Residency

Question

My internship is coming up soon and I'm nervous. What can I expect?

Response from Geoffrey A. Talmon, MD Assistant Professor, Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska

Medical students spend 4 years waiting for the magic of graduation day. My own graduation ceremony made me feel like a transformation had occurred in me and my colleagues. We put on our robes, wore costume-like hoods, and heard a lot of Latin words. Soon after, my parents and nonmedical friends started calling me "doctor" and asked medical questions with more frequency. I remember feeling a twinge of excitement when I started signing checks with an "MD" after my name. Throughout all of it, though, I was terrified for July 1, the start of my internship. Nothing particularly magical -- no epiphanies of knowledge or confidence -- had occurred when I received my diploma, and I had heard plenty of stories about "intern mistakes."

The step from your final year of medical school to your residency is probably one of the largest you will ever face in your career. The amount of responsibility you carry in residency is markedly different from what you had as a student. On wards in medical school, for example, it was sufficient to know the basics about your patient's disease and the global points about its treatments and complications. You were asked to write a daily note, observe or minimally participate in procedures, and answer questions from your attendings. In contrast, as a resident, you are writing admission orders, discharge orders, surgery orders, and operative notes. You need to know not only what drug to give, but the correct dose, frequency, and potential interactions. You are the one handling issues that occur in the middle of the night.

Although it's normal to feel nervous about your internship, it helps to know that there are resources in place to assist you with your responsibilities as a newly minted doctor. Most hospitals have clinical decision support tools with defined algorithms that help with diagnosing and treating your patients. These tools are good not only for ensuring that your patients receive proper care, but also for teaching you the "proper" way to handle specific issues. Additionally, new rules passed by the Accreditation Council for Graduate Medical Education (ACGME) have upped the amount of required supervision that new house officers receive, meaning it is less likely you will "fly solo."

Starting out as a resident, one of the other issues that caused me great angst was work hours. The traditional way that medicine handled the student-to-resident transition was to give interns as much material as possible to learn through abundant call and inpatient rotations. One positive aspect of the ACGME work rules is that demands on first-year residents are tightly regulated, making time on service less of a burden.

If you can, the best way to help prevent some of the shock is to get exposed to resident duties as a medical student. Most institutions offer subinternship rotations as electives. In these, you essentially function as an intern on the service but you are also closely paired with a supervising resident. That allows you to have responsibilities akin to what you will handle following graduation, but the experience still involves a modicum of handholding. Alternatively, you might try a rotation in a rural or underserved setting; trainees typically get more resident-like autonomy at these sites compared with core teaching hospitals. If neither subinternship rotations nor rural rotations is an option, then be proactive as a student. You can ask supervising physicians to let you write notes and orders or take first crack at dealing with nursing calls. Those experiences can prove to be invaluable in your first month on service as a resident.

No matter your perspective, taking your first night of call as an intern will likely make you at least a little nervous. You can alleviate some of your uneasiness by gaining as much experience as possible during medical school. In addition, keep in mind that there are systems and rules in place that are designed to make your first forays into medicine as a full-fledged doctor less traumatic for both you and your patients.

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